MEDICARE: DR. DIANA ROQUE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	509	PR

General Provider Information

NPI Number	:	1295997138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANA ROQUE

Provider Business Mailing Address
First Line	:	1290 CALLE 54 SE
Second Line	:	URB. LA RIVIERA
City	:	SAN JUAN
State	:	PR
Zip	:	00921-3141
Country	:	US
Telephone Number	:	787-774-3766
Fax Number	:	787-883-6124

Provider Business Practice Location Address
First Line	:	1290 CALLE 54 SE
Second Line	:	URB. LA RIVIERA
City	:	SAN JUAN
State	:	PR
Zip	:	00921-3141
Country	:	US
Telephone Number	:	787-774-3766
Fax Number	:	787-883-6124

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2008
Last Update Date	:	07/01/2008

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Directions to “ DR. DIANA ROQUE ” Practice Location

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